2026 Step Therapy Criteria — Pharmacy step edits for behavioral health drugs
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Defines Meridian Health Plan of Michigan step therapy requirements for select antidepressants, antipsychotics (oral), dextromethorphan/bupropion products, and trazodone; applies to medication coverage and prior authorization decisions for members of the plan.
No material clinical or coverage changes in this revision.
Step Therapy Coverage Criteria
Antidepressants — Covered when ALL of the following are met
Covered when ALL of the following are met
Step 1 list: Bupropion SR/XL, Citalopram, Duloxetine, Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline, Venlafaxine IR/ER.
Oral Antipsychotics — Covered when ALL of the following are met
Covered when ALL of the following are met
Step 1 list includes oral formulations of Aripiprazole, Asenapine Maleate, Brexpiprazole, Cariprazine HCl, Lumateperone Tosylate, Lurasidone HCl, Olanzapine, Paliperidone, Quetiapine Fumarate, Risperidone, Xanomeline/Trospium Chloride, or Ziprasidone HCl.
Auvelity (Dextromethorphan/Bupropion) — Covered when ALL of the following are met
Covered when ALL of the following are met
Specific Step 1 lists include multiple SSRI/SNRI and bupropion formulations.
Trazodone — Covered when ALL of the following are met
Covered when ALL of the following are met
Step 1 includes trazodone 100 mg and 150 mg tablets; Step 2 is Raldesy 10 mg/mL oral solution. Patient must have tried a tablet dosage form of generic trazodone (>=1-day supply in prior 180 days) before Raldesy coverage unless exception applies.
Coverage criteria for Raldesy
Coverage for Raldesy (trazodone oral solution) is provided when ANY of the following conditions are met:
Step 1 tablet options listed: trazodone 50 mg, 100 mg, 150 mg; Step 2 option: Raldesy 10 mg/mL oral solution
Document swallowing difficulty as part of prior authorization.
Document current or prior use of Raldesy to support approval.
Step 1 — Initial Therapy
Step 1 — Initial therapy lists of preferred agents
Step 1 lists (initial preferred agents)
Specific products enumerated in the Step 1 lists (chunks 4 and 13).
Step 1 — tablet trial (preferred initial agents — tablet dosage forms)
Step 1 — preferred initial agents (tablet dosage forms):
Patient must have tried a tablet dosage form of generic trazodone (>=1-day supply in prior 180 days) before Raldesy coverage will be provided unless exception applies.
Step Therapy Rules and Tables
| Rule | Requirement / Notes |
|---|---|
| Step therapy requirement | |
| Members must trial the listed Step 1 agents before coverage of Step 2 products; a Step 1 trial is defined as at least a 1-day supply within the prior 180 days. Exceptions include documented current use or prior use of the Step 2 product and specified clinical exceptions (e.g., suicidal ideation for select products). |
| Step | Required trial / Allowed options |
|---|---|
| Step 1 (tablet trial) | |
| Trial of a tablet dosage form of generic trazodone — listed tablet strengths: 50 mg, 100 mg, or 150 mg. Trial must be at least a 1-day supply within the prior 180 days to satisfy Step 1 requirement for Step 2 consideration. | |
| Step 2 (Raldesy) | |
| Raldesy (trazodone 10 mg/mL oral solution) may be approved if Step 1 trial criteria are met, or if the patient cannot swallow tablets, or if the patient is currently taking or has previously taken Raldesy. |
Prior Authorization & Documentation Requirements
PA requires documented Step 1 trial or allowed exception
Prior authorization requires evidence that the member has met the Step 1 trial requirement within the prior 180 days (at least a 1-day supply of a listed Step 1 agent), or documentation of an allowable exception such as current use, prior use of the Step 2 product, or documented suicidal ideation where specified.
- Step 1 trial = at least a 1-day supply in the prior 180 days.
- Exceptions include current or prior use of the Step 2 product and suicidal ideation for specified products.
Raldesy prior auth requires tablet trial or exception
Prior authorization for Raldesy is contingent on meeting the trazodone step therapy criteria: a documented trial of a generic trazodone tablet (≥1-day supply within the prior 180 days) or documentation of an allowed exception (difficulty swallowing tablets, or current/prior use of Raldesy).
- Step 1 tablet options: trazodone 50 mg, 100 mg, or 150 mg.
- Step 2 option: Raldesy 10 mg/mL oral solution.
General step therapy: require Step 1 before Step 2 unless exception
Members must trial the listed Step 1 agents for the applicable drug class before Step 2 products will be approved, unless a stated exception applies (e.g., current/prior use of the Step 2 product or documented suicidal ideation for specific products).
- Step 1 trial is defined as at least a 1-day supply within the prior 180 days.
- Exceptions are explicitly stated per product (for example, Exxua and Auvelity).
Two-step sequence for trazodone → Raldesy
Trazodone step therapy follows a two-step sequence: Step 1 requires a trial of generic trazodone tablets (listed strengths); Step 2 is Raldesy oral solution, which may be approved only if Step 1 criteria are met or a specified exception is documented.
- Step 1: trazodone 50 mg, 100 mg, or 150 mg tablet trial.
- Step 2: Raldesy 10 mg/mL oral solution; approval allowed for inability to swallow tablets or current/prior Raldesy use.
Document prior Step 1 trials or qualifying exception
Document prior trials of required Step 1 agents by showing at least a 1-day supply within the prior 180 days, or provide documentation of current/prior use of the requested Step 2 product or a qualifying clinical exception.
- Acceptable evidence: prescription records showing ≥1-day supply in the prior 180 days or clinical notes documenting current/prior use.
- Exceptions (e.g., suicidal ideation, swallowing difficulty) must be documented in the record.
Documentation for tablet trial or swallowing difficulty (Raldesy)
When requesting Raldesy, document prior use of a tablet dosage form of generic trazodone (at least a 1-day supply in the prior 180 days) or document documented swallowing difficulty or current/past use of Raldesy to support approval.
- Required tablet trial evidence: at least a 1-day supply of trazodone tablet in prior 180 days.
- If patient cannot swallow tablets, document swallowing difficulty in the clinical record.
Denial risk if Step 1 antidepressant trial not documented
Coverage will be denied for Step 2 antidepressant requests if the prerequisite Step 1 drug trial (at least a 1-day supply within the prior 180 days) is not documented and no exception applies.
- Ensure the record shows the required Step 1 agent trial or an applicable exception before submitting prior authorization.
Denial risk if two Step 1 oral antipsychotic trials not documented
Coverage will be denied for Step 2 oral antipsychotic (Fanapt) requests unless the patient has tried two Step 1 oral antipsychotics (each at least a 1-day supply within the prior 180 days) or an allowed exception is documented.
- Trials of two distinct Step 1 oral antipsychotics must be documented in the prior 180 days.
- A trial of the brand-name equivalent of a generic Step 1 product counts toward the requirement.
Auvelity requires SSRI/SNRI plus bupropion trial or exception
Coverage for Auvelity will be denied unless the patient has trialed a generic SSRI or SNRI AND bupropion within the prior 180 days, unless an exception (current suicidal ideation, agitation with Alzheimer's disease, or current/prior Auvelity use) is documented.
- Required: SSRI or SNRI plus bupropion trial within previous 180 days (any duration).
- Document any applicable exception in the clinical record to avoid denial.
Raldesy prior tablet trial required (or documented exception)
For Raldesy, coverage requires a prior trial of a tablet dosage form of generic trazodone (at least a 1-day supply in the prior 180 days); approval may alternatively be supported by documented inability to swallow tablets or current/prior use of Raldesy.
- Prior tablet trial: at least a 1-day supply of trazodone tablet within prior 180 days.
- Allowed exceptions: documented swallowing difficulty or current/past Raldesy use.
Lookback Window, Definitions, and Exceptions
Continuation and Renewal Considerations
Continuation / Current or prior use exceptions — criteria for continuation or renewal when prior use documented
Continuation/renewal exceptions — approve when ANY of the following are met:
Stated for Exxua, Fanapt, and Auvelity in policy details.
Policy Background
This policy organizes selected behavioral‑health medications into a two‑tier Step 1 / Step 2 structure within each drug class. For each class (antidepressants, oral antipsychotics, dextromethorphan/bupropion products, and trazodone), Step 1 lists lower‑step, generally generic agents that must be tried before coverage of higher‑step products is considered; Step 2 lists the higher‑step or brand products subject to prior authorization.
Prior trials of Step 1 agents are assessed using a lookback window of 180 days. A qualifying Step 1 trial is documented by evidence of at least a 1‑day supply of a listed Step 1 agent within that 180‑day period. Where specified in the class criteria, one Step 1 trial (antidepressants) or two Step 1 trials (oral antipsychotics) are required before Step 2 coverage will be provided.
The policy also specifies clinically‑based exceptions that permit approval of certain Step 2 agents without prerequisite Step 1 trials. Examples include approval of Exxua or Auvelity when current suicidal ideation is documented, and allowance for Step 2 approval when the member is currently taking or has previously taken the Step 2 product.
For trazodone specifically, the policy requires a tablet dosage trial of generic trazodone (Step 1) before approving the Step 2 product Raldesy, but allows Raldesy to be approved if the patient has difficulty swallowing tablets or is currently/formerly taking Raldesy.
Policy Revision History
Policy updated and published with effective date 2026-08-01 reflecting step therapy criteria for antidepressants, oral antipsychotics, dextromethorphan/bupropion (Auvelity), and trazodone (including Raldesy).
Last policy review completed (document updated 08/01/2026).
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